Journal of Sleep Disorders and Medical Care

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RESEARCH ARTICLE Volume 1 - Issue 1 | DOI: http://dx.doi.org/10.16966/jsdmc.105

Cognitive Behavioral Treatment for Insomnia in Older Adults with Mild

Cognitive Impairment in Independent Living Facilities: A Pilot Study
Cassidy-Eagle E1*, Siebern A1,2, Unti L3, Glassman J1,3, and O’Hara R1,4
1
Department of Psychiatry & Behavioral Sciences, Stanford University School of Medicine, USA
2
Fayetteville Veterans Affairs Medical Center, USA
3
ETR, Scotts Valley, CA USA
4
Sierra Pacific Mental Illness Research Education and Clinical Centers (MIRECC), Veterans Affairs Palo Alto Health Care System, USA

*
Corresponding author: Erin Cassidy-Eagle, Department of Psychiatry & Behavioral Sciences, Stanford University School of Medicine, USA, Tel:
(650)736-7350; E-mail: ecassidy@stanford.edu

Received: 04 Dec, 2017 | Accepted: 12 Feb, 2018 | Published: 19 Feb, 2018

Citation: Cassidy-Eagle E, Siebern A, Unti L, Glassman J, O’Hara R
(2018) Cognitive Behavioral Treatment for Insomnia in Older Adults
With Mild Cognitive Impairment in Independent Living Facilities:
A Pilot Study. J Sleep Disord Med Care 1(1): dx.doi.org/10.16966/
jsdmc.105
Copyright: © 2018 Cassidy-Eagle E, et al. This is an open-access
article distributed under the terms of the Creative Commons
Attribution License, which permits unrestricted use, distribution, and
reproduction in any medium, provided the original author and source
are credited.
Abstract
Objectives: Sleep disturbance is common in older adults and is one
of the most frequent symptoms observed in older adults with Mild
Cognitive Impairment (MCI). Older adults in residential care settings
are more likely to suffer from psychiatric, medical and cognitive (i.e.,
MCI) impairments than those still independent in the community.
Interventions targeting insomnia are ideal given the evidence that
treatments are very successful for a broad range of individuals;
improvements have the potential to broadly impact public health;
and further, sleep represents a modifiable risk factor for a range
of other disorders, such as declining cognition, depression, and
functional impairment. What remains to be established is whether or
not established treatments, specifically Cognitive Behavioral Therapy
for insomnia (CBT-I), can be successfully used with older individuals
who have both impaired sleep and MCI. This study aims to test
whether CBT-I is effective in improving the sleep of older adults with
insomnia and mild cognitive impairment.
Methods: A six-session, adapted version of a cognitive behavioral
intervention for insomnia was administered to older adults (N=28)
across two residential facilities. Participants were randomly assigned
to either the sleep intervention or an active control group.
Results: The intervention had a highly significant (Cohen’s d ≥ 1.9,
p<0.001) effect of improving sleep outcomes for 4 of the 5 outcome
variables at both follow up time points, measured by actigraphy.
Conclusions: Nonpharmacological interventions such as CBT-I may be
beneficial for people with MCI. Targeting sleep has the potential to
broadly impact public health, including in people with MCI.
Keywords: Insomnia; MCI; Older adults; CBT-I; Residential care
Introduction
More than 50% of adults over the age of 65 report serious
problems with sleep [1]. Sleep disturbance increases with age,
particularly among women and those with concurrent medical
or psychiatric conditions [2]. Further, the presence of sleep
disturbance is a risk factor for declining health status [3].
Specific aspects of sleep that are significantly worse in older
adults with insomnia include increased sleep latency, number
of awakenings after sleep onset, and overall sleep efficiency
[4]. Such problems are frequently secondary to medical,
psychological, environmental and behavioral causes, as well
as complications that can result from prescription and non-
prescription medications [5]. Notably, sleep disturbances are
more prevalent and severe in those with MCI compared to those
with no impairment [6,7]. Growing evidence suggests that
sleep problems may reflect an intermediary state of cognitive
functioning between normal and cognitive impairment, and
may be predictive of progression to dementia [8,9].
Several meta-analyses of sleep interventions, such as
CBT-I, support the finding that sleep disturbance is very
amenable to change [10,11] with treatment resulting in robust
improvements in functioning across the lifespan. Morin et
al. [12] found that an 8-week CBT intervention with older
adults in the community resulted in significant improvements
that were maintained even a year later, including decreases
in sleep latency, Wake After Sleep Onset (WASO), and early
morning awakenings, as well as an increase in sleep efficiency.
Discussion of ‘sleep hygiene’ can be useful to make sure that
individuals are behaving in ways that promote good sleep,
from how much alcohol they consume and when, to making
sure the temperature is somewhat cool in their bedroom.
The interventions also include the well-supported behavioral
components, like stimulus control and sleep restriction
procedures, which set a consistent rise time, designating a sleep
opportunity window and recommending that patients get out

J Sleep Disord Med Care | JSDMC 1

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of bed if unable to sleep (instead of staying in bed and being
frustrated), in addition to other instructions. CBT can also
include relaxation to help manage physiological arousal and
cognitive therapy (restructuring) to address the thoughts and
beliefs that serve to perpetuate the insomnia such as “everyone
needs 8 hours of sleep”.
Residential Care Facilities for the Elderly [RCFEs] e.g.,
Independent Living Facilities (ILF) strive to provide an
environment that allows and cultivates independence, while
simultaneously providing assistance for those residents with
functional and cognitive limitations. Residents may present
with multiple medical and psychological co-morbid disorders,
and appear to be more likely to suffer from both disturbed
sleep [13] and Mild Cognitive Impairment (MCI) [14] than
skilled nursing facility or home-dwelling adults. Thus, RCFEs,
particularly ILFs, are an ideal and critical setting in which
to develop effective interventions for sleep disturbance in
residents with MCI. There is evidence that CBT-I is effective in
the geriatric population although studies are limited in the area
examining CBT-I and its effectiveness in a geriatric population
with MCI residing in residential care facilities, specifically
independent living facilities.
Is CBT effective in those with MCI?
The success of CBT relies on certain cognitive processes,
including one’s ability to process and incorporate new
information in order to subsequently shift one’s behavior and
mood. Although complaints of attention and concentration
are common amongst those with insomnia, complaints of
memory or executive functioning are less common [15].
Sleep latency, night time awakening, duration of sleep and
sleep efficiency were all compromised in patients with MCI,
even when analyses were controlled for clinical levels of
anxiety and depression [16]. Cognitively, deficits in executive
processes (e.g., planning, problem solving), memory and
language functions also occur more frequently in MCI and
are particularly important to assess in light of their potential
impact on treatment given the cognitive processing involved
in CBT. MCI affects 15-25% of adults over the age of 70, with
about 10% of this group progressing to dementia each year [17-
19]. There is growing evidence that a bidirectional relationship
between sleep disturbances and cognitive impairment exists
[20]. Prospectively, sleep disturbance has been linked to the
emergence of cognitive deficits [6], and has been identified
as a risk factor and/or prodromal syndrome of various
neurodegenerative diseases [21]. For example, recent work by
Diem et al. [22] found that lower sleep efficiency and longer
sleep latencies in older women were associated with a 1.5 and
1.4 greater odds of developing MCI or dementia within five
years.
Patients with executive dysfunction, often present with
MCI [23], have also been identified as poor responders to
pharmacotherapy, such as anti-depressants [24], creating a
need for therapeutic alternatives. Although there is evidence
Citation: Cassidy-Eagle E, Siebern A, Unti L, Glassman J, O’Hara R (2018) Cognitive Behavioral Treatment for Insomnia in Older Adults
With Mild Cognitive Impairment in Independent Living Facilities: A Pilot Study. J Sleep Disord Med Care 1(1): dx.doi.org/10.16966/
jsdmc.105
Journal of Sleep Disorders and Medical Care
Open Access Journal
that those with cognitive impairment can benefit from
structured psychotherapy, such as CBT [25], Interpersonal
[26] or Problem Solving Therapy [27,28], much remains to be
learned about how MCI may moderate the effects of CBT-I for
sleep and what adaptations are needed to maximize the effects
of treatment. Adaptations of CBT interventions targeting other
behaviors (e.g. anxiety) among older adults with MCI have
proven to be successful [29]. This study contributes new data on
the degree to which adaptations to CBT, such as repetition and
increased opportunities for practice, aid older adults in RCFE
settings who have MCI and sleep disorders.
Our hypotheses
From baseline (T1) to the 4 month-follow-up (T3) time
points, ILF residents with both sleep disturbances and
MCI assigned to receive the adapted CBT-I will exhibit: 1)
significant improvements in objective measures of sleep-onset
latency, wake time after sleep-onset, total sleep time, and sleep
efficiency, as measured by actigraphy, compared to the delayed
treatment group, and 2) significant decreases in self-reported
frequency and severity of insomnia symptoms, as measured
by the Insomnia Severity Index (ISI), compared to the delayed
treatment group.
Methods
The study employed a two-arm Individual Randomized
Group Trial (IRGT) with residents from two RCFE (N=28), with
randomization at the resident level to the adapted intervention
or delayed treatment group. Participants were randomized to
either a 6-session CBT-I intervention group or an active control
nutrition class. The active control group was a nutrition class
as it would not have an impact on sleep parameters and was of
interest for participant recruitment.
The sample (N=28) included participants from two local
Independent Living Facilities (ILF) in the Santa Cruz area from
2014-2015. Recruitment was facilitated by flyers in all resident
mailboxes and at in-person talks by the PI about common sleep
changes with age.
Participants were 28 older adults (24 females-4 males; mean
age, 89.36 years), meeting the key inclusion criteria of meeting
diagnostic criteria for insomnia according to the DSM-IV [30],
and the core clinical criteria for MCI used by healthcare workers
without access to advanced imaging techniques [31] (i.e.,
subject memory complaints, preservation of independence in
functional abilities, performance on at least one of the cognitive
tests at 1.5 SD below published age/educational matched
normative means, and no major neurocognitive disorder).
Out of the 46 potential participants identified, 18 participants
were excluded from the study due to acute stressor (n=6),
not meeting insomnia diagnostic criteria (n=6), unwilling to
commit time to study (n=2), screened positive on apnea screen
and were unwilling to treat (n=1), unwilling to do apnea screen
(n=1), unable to reach/make contact (n=1), and one that was
determined to be intoxicated at screening visit (n=1).
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Intervention
The CBT-I intervention was administered by a behavioral
sleep medicine specialist (psychologist who is certified by
American Board of Sleep Medicine). The CBT-I intervention
was delivered in a group format in 6 sessions spread over 7
weeks. One week break was taken between sessions 5 and 6
to give participants time implementing recommendations on
their own. A phone call was completed with each participant
on the off week to check-in and see if they had any questions
or concerns. Adaptations to the CBT-I intervention included
specific adjustments to content, including decreasing the
amount of content covered and providing brief, focused
rationale for the treatment components leaving time for review
and repetition of content covered. Larger handouts for those
with visual impairments were distributed to patients. We
also provided larger writing spaces for those with deficits in
fine-motor skills. In addition, changes in the delivery of the
intervention benefitted from utilizing learning and memory
aids to enhance understanding and retention, such as insuring
sufficient time and opportunity to review material and ask
questions, adjusting pace to account for changes in information
processing, repeating key material and adding troubleshooting
and reminder calls between intervention sessions.
Outline of the CBT-I content and sessions
Session 1: Overview of sleep regulation, changes with aging
and discussion of sleep hygiene.
Session 2: Review of previous week’s material. Sleep
scheduling (sleep compression) and stimulus control guidelines.
Session 3: Review of previous week’s material. Follow
up on adherence to prescribed sleep compression window
and stimulus control guidelines. Constructive worry and
introduction to diaphragmatic breathing.
Session 4: Review of previous week’s material. Follow up
on adherence to prescribed sleep compression window and
stimulus control guidelines. CBT model of thoughts, feelings,
and behaviors. Introduction to progressive muscle relaxation.
Session 5: Review of previous week’s material. Follow up
on adherence to prescribed sleep compression window and
stimulus control guidelines. CBT model of thoughts, feelings,
and behaviors and cognitive restructuring. Introduction to
visualization.
Session 6: Review of previous week’s material. Follow up
on adherence to prescribed sleep compression window and
stimulus control. Review of class CBT-I components and what
was helpful.
Sleep compression was utilized rather that sleep restriction
and included assessing the average amount of time in bed each
week and incrementally delaying bedtime by 30 minutes or
awakening 30 minutes earlier. This serves to compress the time
in bed window to bring window closer to actual sleep time.
Citation: Cassidy-Eagle E, Siebern A, Unti L, Glassman J, O’Hara R (2018) Cognitive Behavioral Treatment for Insomnia in Older Adults
With Mild Cognitive Impairment in Independent Living Facilities: A Pilot Study. J Sleep Disord Med Care 1(1): dx.doi.org/10.16966/
jsdmc.105
Journal of Sleep Disorders and Medical Care
Open Access Journal
Stimulus control guidelines were modified to include staying
in bed to rest if there was risk of fall or if being in bed due
to chronic pain was more comfortable versus other location.
Cognitive components included constructive worry time and
cognitive restructuring for dysfunctional beliefs and attitudes
about sleep.
All participants underwent a detailed assessment on
all outcomes at three time points (baseline-T1, post-
intervention-T2 and a 4 month follow-up-T3), including sleep,
cognitive, mood, physical performance, health QOL, pain and
demographic measures. Additionally, sleep apnea was screened
with in-home ambulatory equipment (RESMED Apnea Link
Plus) and patients were referred out for treatment before
randomization if they had an apnea hypopnea index ≥ 30 and/
or were not utilizing CPAP treatment.
Primary outcome measures
Insomnia Severity Index (ISI) [32] is given at baseline (T1),
post-intervention (T2), and at 4 month follow up (T3). The
ISI is a brief screening questionnaire used to assess severity
of insomnia symptoms. It consists of 7 questions each rated
using a Likert-type scale ranging from 0-4 with higher scores
indicating more acute symptoms of insomnia. ISI has an
internal consistency of 0.74.
Objective sleep parameters of total sleep time sleep latency
(SL), wakefulness after sleep onset (WASO), total sleep time
(TST), and sleep efficiency (SE) were measured using Actigraph
wGT3x (Actigraph Corporation Pensacola, FL) which records
continuous physical activity and sleep/wake estimates using an
accelerometer and light sensor. The participants wore the device
on their non-dominant hand for a week at time points baseline
(T1), post-intervention (T2), and at 4 month follow up (T3). The
Velcro strap was chosen over a typical watch like band due to
dexterity and fine motor skill issues for some of the participants
and reports of skin sensitivity. The raw actigraphy data, with
recordings of 3 to 8 days in duration, was first downloaded
and reviewed to eliminate technical and situational (e.g., for
example, periods where no activity or light were recorded or
periods that software recognizes as device being “off-wrist”; the
device failed, battery died before sufficient data was recorded,
the device was removed) artifacts, prior to scoring the variables
of interest with validated software. The data was analyzed by a
sleep expert who used standard methodology of self-reported
sleep logs and actigraphic recordings were used for establishing
bedtimes and rise times. Actigraphs were initialized to start
recording, at one minute epochs/intervals, when they were
placed on the participant’s wrist by research personnel. Sleep
log noted ‘bedtimes’ and ‘out of bed’ times were used as ‘scored’
times. If there were no sleep log notation available for a time
point, we marked the time closest to the time that light and
activity levels decreased/increased for a given day. If there was
a significant discrepancy between the sleep log times and the
visual review of data (i.e., signs of extended or protracted light
and activity recordings during a time designated as ‘sleeping’),
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Open Access Journal

adjustments were made to bring the marker within 5 minutes
of the shift in activity level. Total sleep time, sleep latency,
wakefulness after sleep onset, and sleep efficiency (time in bed/
total sleep time) were then calculated using ActiLife 5 Software
that uses Cole and Kripke’s 1992 sleep scoring algorithm.
Actigraph data was reviewed and scored separately from all
other data and randomized group assignment reports, with the
exception of sleep logs and subject ID (which was a consecutive,
temporally assigned number).
Data analysis
Multilevel analyses were used to provide estimates of the
intervention’s effect on the outcomes of interest, adjusting for
the correlation between residents within the same treatment
delivery groups. Stata was used to conduct the multilevel
analyses. In these analyses the outcome variable was regressed,
using linear multilevel regression models (all outcomes are
continuous variables), against the following independent
variables: indicator variable denoting intervention condition,
baseline measure of the dependent variable; and covariates that
were imbalanced across arms. Cohen’s d was computed from
the regression coefficient t-statistics as a measure of effect size
[33,34], and p-values were from the Wald test for significance
of a regression coefficient.
Results
Table 1 includes baseline means for selected demographic,
covariates and primary outcomes by treatment arm for all
participants. The table also displays the p-values for independent
sample t-tests for baseline differences between treatment and
control group means. There were no statistically significant
differences in any factors across arms, so randomization efforts
were successful in balancing the groups on a wide range of
characteristics. The only variable that was close to significance
is the SF-36 Physical quality of life rating, with a p=0.11;
therefore it was included as the only covariate besides baseline
outcome in the regression analyses (a cutoff of p<0.15 was used
for concluding covariates were “imbalanced”) [35]. Table 2
shows the means and standard deviations for all of the sleep
parameters as measure for both T1 and T3. The effect of the
intervention on the secondary neuropsychological outcome
variables are reported elsewhere [36].
Table 3 shows that the intervention had a highly significant
(p<0.005) effect in the desired direction of improving sleep
outcomes for 4 of the 5 outcome variables at both follow up
time points. In other words, sleep latency; wake after sleep
onset, sleep efficiency, and insomnia severity all were improved
significantly in the treatment groups relative to the control
groups. Effect sizes were large, with absolute values of Cohen’s
d greater than 1.
Discussion
Results of our current investigation, utilizing an adapted
CBT-I intervention with older adults in ILFs who suffer from
sleep disturbance and MCI, indicate that we have been able to
improve both objective and subjective ratings of sleep quality. At
this stage it appears that this 6-session CBT-I group intervention

Table 1: Selected Baseline Characteristics (means) by Treatment Condition

Intervention (n=14) Active Control (n=13) Independent samples t-test
Mean (SE) Mean (SE) p-value
Age 89.36 (1.23) 88.69 (1.35) 0.72
Body Mass Index (BMI) 23.91(1.02) 24.66 (1.06) 0.61
Education (years) 15.58 (0.43) 15.5 (0.42) 0.89
Apnea-Hypopnea Index (AHI) 12.86 (2.86) 7.92 (2.50) 0.21
Takes Sleep Medication 0.57 (0.14) 0.42 (0.15) 0.45
Number of Prescription Medications 5.36 (0.85) 6.46 (1.58) 0.54
Number of chronic medical conditions 3 (0.36) 3.38 (0.81) 0.67
Activities of daily living (ADLs) 5.85 (0.15) 5.92 (0.08) 0.70
Instrumental activities of daily living (IADLs) 5.15 (0.60) 5.92 (0.42) 0.31
Montreal Clinical Assessment (MoCA) 23.64 (0.80) 23.5 (1.01) 0.91
Insomnia Severity Index (ISI) 15.29 (0.62) 14.85 (1.07) 0.72
Reduced scale of morningness-eveningness Q 17.5 (0.83) 17.95 (0.89) 0.71
Geriatric Depression Scale 2.85 (0.79) 2.75 (0.82) 0.93
Geriatric Anxiety Inventory 2.88 (1.09) 3.38 (0.90) 0.74
Grip Strength Left Hand (pounds) 37.48 (4.72) 33.07 (3.78) 0.48
Grip Strength Right Hand (pounds) 38.91 (4.05) 34.99 (3.36) 0.47
Short Physical Perf. Battery Total (SPPB) 5 (0.88) 3.83 (0.98) 0.39
SF36-Physical health 49.77 (2.20) 44.08 (2.66) 0.11*
SF36-Mental health 51.92 (2.72) 54.92 (1.69) 0.37
Rating of Pain Now 0.58 (0.37) 0.92 (0.45) 0.56
Sleep latency (minutes) 11.03 (3.53) 11.23 (2.62) 0.96
Total sleep time (minutes) 434.61 (15.54) 422.22 (17.74) 0.61
Wake after sleep onset (minutes) 104.24 (11.52) 104.42 (19.60) 0.99
Sleep Efficiency (percent) 79.20 (2.24) 78.94 (3.33) 0.95
*
added as covariate to outcome regression model

Citation: Cassidy-Eagle E, Siebern A, Unti L, Glassman J, O’Hara R (2018) Cognitive Behavioral Treatment for Insomnia in Older Adults
With Mild Cognitive Impairment in Independent Living Facilities: A Pilot Study. J Sleep Disord Med Care 1(1): dx.doi.org/10.16966/ 4
jsdmc.105
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Journal of Sleep Disorders and Medical Care
Open Access Journal

Table 2: Primary Sleep Outcomes: Means and Standard Deviations by Treatment Relative to Active Control
Time 1 Time 3
Treatment Control Treatment Control
Variable n Mean (SD) n Mean (SD) n Mean (SD) n Mean (SD)
ISI 14 15.29 (2.33) 13 14.85 (3.85) 12 3.25 (2.05) 11 12 (3.11)
LATENCY 11 11.03 (11.69) 13 11.23 (9.45) 12 1.93 (3.57) 10 12.52 (9.84)
WASO 11 104.24 (38.21) 13 104.42 (70.68) 12 46.95 (25.09) 10 81.70 (44.49)
TST 11 434.61 (51.53) 13 422.22 (63.97) 12 379.50 (75.13) 10 432.15 (46.82)
EFFICIENCY 11 79.20 (7.44) 13 78.94 (12.02) 12 88.04 (7.19) 10 82.30 (7.82)

Table 3: Primary Sleep Outcomes: Results of Multilevel Regression Analyses

Variable n Beta Std Error p1 Cohen’s d2
ISI -9.412 0.930 <.001 -4.22
LATENCY -1.137 0.287 <.001 -1.73
WASO 21 -2.921 0.550 <.001 -2.32
TST -47.632 20.486 .02 -1.02
EFFICIENCY 1381.257 319.021 <.001 1.89
1
p-value is for Wald test of regression coefficient
2
Cohen’s d guidelines: 0.2 small ES, 0.5 medium ES, 0.8 large ES

has led to significant improvements in sleep parameters in older
adults in residential settings who also frequently suffer from
mild cognitive deficits. This study was a small pilot study and
future research should include a randomized controlled study.
Further limitation is the sample overall included healthy and
highly educated participants and further study should examine
additional demographics. Future study is needed to further
explore the possible impact on cognitive functioning that result
from CBT-I.
This study examined whether or not CBT-I, an effective
nonpharmacological intervention, is effective at improving the
sleep of older adults experiencing insomnia and mild cognitive
impairment. These promising results support the need for
more work with individuals suffering from mild cognitive
impairment to explore the extent that sleep treatments could
result in improved health. Nonpharmacological interventions
that may extend the functional window experienced by older
adults exhibiting mild cognitive impairment have the potential
to profoundly impact quality of life.
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Citation: Cassidy-Eagle E, Siebern A, Unti L, Glassman J, O’Hara R (2018) Cognitive Behavioral Treatment for Insomnia in Older Adults
With Mild Cognitive Impairment in Independent Living Facilities: A Pilot Study. J Sleep Disord Med Care 1(1): dx.doi.org/10.16966/ 5
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